Ohio
|[pic] |OHIO DEPARTMENT OF PUBLIC SAFETY | |
| |BUREAU OF MOTOR VEHICLES | |
| | | |
| |INDIVIDUAL’S REQUEST FOR NATIONAL DRIVER REGISTER (NDR) | |
| |FILE CHECK IN ACCORDANCE WITH THE | |
| |PRIVACY ACT OF 1974 (PUBLIC LAW 93-579) | |
|The National Driver Register (NDR) contains only a listing of names and related identification, provided by State driver licensing officials, of those drivers |
|whose driver licenses have been cancelled, denied, revoked, or suspended or who have been convicted of certain serious traffic violations such as Driving Under the|
|Influence of Alcohol. The NDR does not contain a list of any other drivers. If you have not had a driver license cancelled, denied, revoked, or suspended or have |
|not been convicted of serious traffic violations, you would not be listed in the NDR. Every individual is entitled, however, to request a check of the NDR records |
|to determine whether or not they appear on the NDR file. A reply is made to every valid NDR inquiry. The record content for those persons who are listed in the NDR|
|files is limited to identification of the state(s) which have taken action to cancel, deny, revoke, or suspend or have records of conviction of serious traffic |
|violations. Any specific information about the driver history, or a request, for the entire driver history, can be obtained only from the state(s) where the |
|detailed information is recorded. If the NDR has a record on you, the full record will be copied and sent to you including older records which may have contained a|
|reason for license cancellation, denial, revocation, or suspension. In addition, if such information has been disclosed by the NDR, the recipient of the |
|information will also be identified. The name and address of the State driver licensing official will be provided for each State listed as having reported |
|information on you to the NDR. |
|TYPE OR PRINT LEGIBLY AVOID DELAYS - INQUIRIES THAT CANNOT BE READ WILL NOT BE PROCESSED |
|FULL LEGAL NAME (FIRST, MIDDLE, AND LAST AS SHOWN ON YOUR DRIVER LICENSE) |
| |
|OTHER NAMES USED (MAIDEN, PRIOR NAME, NICKNAME, PROFESSIONAL NAME, OTHER) |
| |
|ADDRESS (NUMBER AND STREET WITH APARTMENT NUMBER IF ANY OR RURAL ROUTE / CARRIER AND BOX NUMBER- AS SHOWN ON YOUR DRIVER LICENSE) |
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|CURRENT MAILING ADDRESS IF DIFFERENT (NUMBER, STREET, APARTMENT NUMBER OR RURAL ROUTE / CARRIER AND BOX NUMBER) |HOME TELEPHONE (VOLUNTARY) |
| |( ) - |
|CITY |STATE |ZIP |WORK TELEPHONE (VOLUNTARY) |
| | | |( ) - |
|DRIVER LICENSE NUMBER AND STATE |SOCIAL SECURITY NUMBER (VOLUNTARY) |
| | |
|DATE OF BIRTH |SEX |EYE COLOR |HEIGHT |WEIGHT |
| | | | | |
|UNDER THE PRIVACY ACT OF 1974, I HAVE THE RIGHT TO REQUEST RECORD(S) PERTAINING TO ME FROM THE NDR AND TO CORRECT ANY ERROR IN SUCH RECORD(S).I HEREBY, WITH MY |
|SIGNATURE, AUTHORIZE A ONE - TIME FILE SEARCH OF THE NDR. |
|APPLICANT SIGNATURE |DATE |
|X | |
|Notary: |
|Sworn to and subscribed in my presence this day of , 20 in County, |
|State of . |
|(Notary Seal) |
|Signature of Notary Public X My commission expires |
|STATE USE ONLY |
|DATE RECEIVED |DATE SENT |CONTROL SECTION |EMPLOYEE VERIFYING APPLICATION IDENTIFICATION |DATE |
|TYPE OF IDENTIFICATION: VALID PHOTO DRIVER LICENSE STATE-ISSUED PHOTO ID |
| |
|BIRTH CERTIFICATE VALID PASSPORT VALID MILITARY ID |
| |
|MILITARY DISCHARGE PAPERS OTHER (SPECIFY) |
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|Requests for National Driver Register (NDR) Record Checks |
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|Who May Request an NDR Record Check |
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|Each person wanting to request a copy of the NDR record on himself or herself (or to know whether such a record exists) should make a written request containing |
|the identifying information on the front side of this form. The information will be used only for identification verification and records search purposes. Forms |
|are available for both types of requests: those made for current or prospective employers and those individuals under the terms of the Privacy Act of 1974. |
| |
|Employer / Employee requests may be completed by either the current or prospective employer or by the current or prospective employee, but (1) the driver must sign|
|and authorize the request, and (2) the results of the NDR check will be mailed only to the current or prospective employer named. If no employer is named or the |
|form is changed, the request will not be processed. |
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|How to Request an NDR Record Check |
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|NDR record check requests must be notarized if mailed. Written requests presented in person shall also be accepted provided that the requesting party can prove his|
|/ her identity through the presentation of a document issued by a recognized organization (e.g., a driver license or a credit card) which contains a means of |
|verification such as a photograph or a signature. |
| |
|NDR results from Employer / Employee Requests will contain only the identification of the state(s) that have reported information on the driver to the NDR and only|
|information reported within the past 3 years from the date of the inquiry. Driver control actions initiated prior to that time, even if still in effect, will not |
|be included. Detailed information to confirm identity or to describe the contents of the driver record can be obtained only from the State(s). The name and address|
|of the driver licensing official will be provided for each state listed. |
| |
|NDR results from Individual-Privacy Act Requests will contain all information listed in the NDR records on the individual and will indicate any disclosures |
|previously made of the information and who received any reports provided. |
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|Requests for record information can be submitted, in writing to the following address: |
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|OHIO BUREAU OF MOTOR VEHICLES |
|ATTN: CDL SPECIAL CASE UNIT |
|P.O. BOX 16784 |
|COLUMBUS, OH 43216-6784 |
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